Chesterbrook Academy

8VAC20-780-160-B · Acceptable forms of documentation of tuberculosis screening are a clearance statement signed by a physician, the physician's designee or an official of the local health department. This statement shall include language that the individual does not have any current symptoms of active tuberculosis, does not have either a risk factor for acquiring tuberculosis infection or a risk factor for progression to active tuberculosis disease as defined by the local health department, or has been treated for these conditions in the past, and is currently free of tuberculosis in a communicable form. Staff #5 who has been working at the center for over 16 months did not have the required TB screening or statement.

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8VAC20-780-130-A · The center shall obtain documentation that each child has received the immunizations required by the State Board of Health before the child can attend the center. Child #1 began attending the center more than two months before the center obtained immunizations.

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8VAC20-780-350-B-4 · The required ratio for children ages three to five years is one staff per ten children. Staff #1 and Staff #6 were observed supervising 25 children in their classroom.

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8VAC20-780-40-E · (Repeat Violation) The operational responsibilities of the licensee shall include ensuring that the center's activities, services, and facilities are maintained in compliance with these standards, the center's own policies and procedures that are required by these standards, and the terms of the current license issued by the department.

The center?s ?Standards for Playground Safety? require staff to ?walk around the playground to always ensure proper supervision of each child? and when ?multiple staff are supervising the group, they shall maintain supervision on opposite sides of the area, rotate, and interact to ensure they can see and/or hear all children.? On 11/04/2024, several groups of children were on the playground together between 3:28 p.m. and 4:17 p.m. Staff #6 reported that when she came out to the playground with her class at 3:48 p.m., Staff #1 and Staff #3 were clustered together talking to another staff member across the fence in the toddler area. As a result, Staff #1 and Staff #3 were not facing or supervising the children. Staff #6 reported that at one point, she separated Child #1 and Child #2 on the slide. Child #1 and Child #2 (both age 2 years) later left the playground through a gate without staff noticing. Child #1 and Child #2 were eventually found in an unknown neighbor?s front yard approximately 152 feet beyond the playground gate and center property.

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8VAC20-780-40-E · Based on staff interviews and record review, licensee failed to ensure operational responsibilities that the center?s activities and services are maintained in compliance with the center?s own policies and procedures that are required by the standards.

Evidence: Staff members (S1, S2, and S3) acknowledged in interviews that on 5/20/24, a child (C1-age 5) was left out on the playground alone when the rest of his class went inside. The center?s policy for playground safety states that staff are to follow the Face to Name process as each child crosses the threshold into the classroom and to complete a final Face to Name once they are all inside the classroom and the door is closed. S3 acknowledged that they failed to do a Face to Name headcount upon returning to classroom as their policy requires.

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8VAC20-780-570-E · Based on observation and interview, the center failed to ensure that two infant?s bottles were dated.

Evidence: The bottles in the refrigerator for C10 and C11 were not dated. In an exit interview on 6/06/24, S1 acknowledged that the bottles weren?t dated as required.

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8VAC20-780-280-B · Based on observation, the provider failed to ensure hazardous substances such as

cleaning material be kept in a locked place preventing access by children. Evidence: The laundry closet located in the center?s hallway was open and contained laundry detergent with the warning label to keep out of reach of children.

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22.1-289.035-A · Based on staff record review, the provider failed to ensure that one of eight employees

underwent background checks every five years. Evidence: The record for S8, contains searches of the central registry dated 08/30/2017 and 11/21/2022 and searches of the criminal history dated 04/11/2018 and 07/03/2023.

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8VAC20-780-350-B-1 · Repeat Violation

Based on observation and interview, the center did not ensure compliance with ratios of staff to children as required. Evidence: Based on observation the center did not maintain the ratio of 1 staff to 5 children in the toddler room. The licensing inspector entered the toddler room at approximately 8:25 a.m. and observed 11 children being cared for by 2 staff members. The classroom staff acknowledged the room was out of ratio at that time as well as other times on other days. Based on observation the center did not maintain the ratio of 1 staff to 4 children in the Infant I room. The licensing inspector entered the Infant 1 Room at approximately 8:46 a.m. and observed 13 infants being cared for by 3 staff members. The classroom staff acknowledged they were out of ratio at that time as well as other times and on other days.

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8VAC20-770-60-C-2 · Based on staff record review, the provider failed to obtain a search of the central registry within 30 days of employment.

Evidence: The record for S6, employed 11/08/2022 did not have results of a central registry search within 30 days of employment. The results of the central registry search for S6 are dated 12/13/2022.

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8VAC20-780-350-B-1 · Based on observation and interviews, the center did not ensure compliance with ratios of

staff to children as required. Evidence: Based on observation the center did not maintain the ratio of 1 staff to 4 children in the Infant I room. The licensing inspector entered the Infant I Room at approximately 9:00 a.m. and observed 15 infants being cared for by 2 staff members. Classroom staff acknowledged they were out of ratio at that time as well as other times. Program Director stated she had been in the classroom but left the Infant I Room out of ratio to answer the door to allow licensing entry into the facility along with building contractors.

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8VAC20-780-350-B-1 · Based on observation and interviews, the center did not ensure compliance with ratios of staff to children as required.

Evidence: 1. Based on observation the center did not maintain the ratio of 1 staff to 4 children in the Infant I room. The licensing inspector entered the Infant I Room at approximately 8:45 a.m. and observed 12 infants being cared for by 2 staff members. 2. Based on observation the center did not maintain the ratio of 1 staff to 8 children in the Beginner I classroom. The licensing inspector entered the Beginner I room at approximately 8:50 a.m. and observed 13 children being cared for by 1 staff. After the inspector entered the room another staff came into the room to bring the class into ratio and then a 3rd staff entered the classroom at 9:08 a.m. 3. The assistant director reports the center is having issues in the mornings keeping within ratio when the children are being dropped off. She states the center is aware of being out of ratio and are trying to fix it.

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8VAC20-780-350-B-1 · Based on observation and interview, the provider failed to ensure that staff-to-child ratios were maintained on 07/28/2022.

Evidence: 1. Upon entering the infant room, the licensing inspector observed 5 infants (ranging from 2.5 months to 11.5 months) with 1 staff. The required ratio is 4:1. 2. Program Director acknowledged the classroom was out of ratio.

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8VAC20-780-270-A · Based on observation, the provider failed to ensure that all equipment of the center was maintained in a clean, safe and operable condition.

Evidence: During the inspection of the Intermediate Classroom, licensing inspector observed multiple plastic covered foam rest mats with rips and tears in the plastic prohibiting proper cleaning and sanitizing.

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